Information about Disenrollment and Contract Termination

Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you:

• Move your permanent residence out of the plan's service area (including incarceration).
• Lose your entitlement to Medicare benefits under Part A and/or are no longer enrolled in Part B.
• Fail to pay the monthly premium (if your plan has one) after your plan has made reasonable efforts to collect the unpaid premium.
• Become desceased.
• Knowingly misrepresent that you expect to receive reimbursement for covered Medicare prescription drug plan drugs through other third-party coverage.
• Enroll in a different prescription drug plan. You will automatically be disenrolled from your previous plan (if it has prescription drug coverage).
• Fail to pay your Part D-IRMAA to the government and CMS notifies the plan to effectuate the disenrollment.

You may also be disenrolled for "disruptive behavior." Disruptive behavior is defined as behavior that substantially impairs UnitedHealthcare's ability to arrange or provide care for you or other plan members. Other Medicare prescription drug plan sponsors may decline your enrollment if you have been disenrolled for disruptive behavior.

In all cases of disenrollment, your plan is required to provide proper notice to you and give you the opportunity to appeal the decision prior to disenrollment.

Disenrollment information

You can request disenrollment from your Medicare Advantage (Part C) plan, your Medicare Special Needs plan (SNP) or Medicare prescription drug (Part D) plan and switch to Original Medicare (Parts A and B) online or by mail/fax:

Medicare Advantage Plan Disenrollment

• Disenrollment Form (Online) Medicare Advantage Plan Disenrollment - Fill out the form and submit the request online.
• Disenrollment Form (PDF) Medicare Advantage Plan Disenrollment (95.11 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Advantage Plan – PFFS Disenrollment

• Disenrollment Form (Online) Medicare Advantage PFFS Plan - Fill out the form and submit the request online.
• Disenrollment Form (PDF) Medicare Advantage PFFS Plan (96.08 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Advantage Prescription Drug Plan Disenrollment

• Disenrollment Form (Online) Medicare Advantage Prescription Drug Plan Disenrollment - Fill out the form and submit the request online.
• Disenrollment Form (PDF) Medicare Advantage Prescription Drug Plan Disenrollment (95.33 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Special Needs Plan Disenrollment

• Disenrollment Form (Online) - Fill out the form and submit the request online.
• Disenrollment Form (PDF) (95.33 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Prescription Drug Plan Disenrollment

• Disenrollment Form (Online) - Fill out the form and submit the request online.
• Disenrollment Form (PDF) (83.95 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Potential for contract termination

Availability of coverage or service areas beyond the end of the current contract year is not guaranteed. Termination or non-renewal of the contract by Centers for Medicare & Medicaid Services (CMS) or UnitedHealthcare^® Insurance Company as authorized by law may end your enrollment in the plan. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do it within the time period required.